Experts critique state pandemic plans

Aug 28, 2006 (CIDRAP News)  Now that most states have issued preliminary or final plans for dealing with pandemic influenza, a group of experts who looked at the public health strategies in the plans has given them a mixed review.

The US Department of Health and Human Services (HHS) issued guidelines in November 2005, but left it to states to make specific plans. HHS Secretary Mike Leavitt has warned states not to rely on the federal government for much help during a pandemic. Since then, most states have released drafts or final versions of their pandemic plans.

Public health experts from three Research Triangle Institute International sites reviewed pandemic plans of 49 states. (Lousiana, which had its pandemic planning summit in April, has not yet released a plan.) They evaluated each state's approach to three activities: vaccination, early epidemic surveillance and detection, and containment. The researchers published their findings in the September issue of Emerging Infectious Diseases.

The researchers found that all 49 plans generally agree about the vaccination priority groups recommended by the Advisory Committee on Immunization Practices (ACIP) and the HHS. The recommendation is to vaccinate healthcare workers first, followed by patients who have chronic or high-risk medical conditions, people aged 65 years or older, close contacts of those who are ill or likely to become ill, and all others.

For surveillance and detection, all states rely on the National Sentinel Physician Surveillance, the 122 Cities Mortality Reporting System, or both. All but two states indicated they would evaluate reports of local clusters or unusual influenza-like cases; 40 (82%) said they would evaluate reports of laboratory-confirmed influenza. Relatively few (12) have or anticipate using real-time syndromic surveillance of influenza-like illness.

Eight states (16%), including California, New York, and Hawaii, are developing procedures for screening international travelers. Other international entry points, such as Seattle, Portland, Chicago, and Atlanta, do not yet have any plans for traveler quarantine and testing.

In their approach to containment measures, most states did not include personal contact-avoidance steps such as staying home from work and keeping sick children at home. Seventeen (35%) states recommend or are considering urging such contact-avoidance steps. Eighteen (37%) cite federal or state regulations about closing schools, businesses, and other institutions during a severe outbreak. Fifteen (31%) indicate the legal ability to quarantine people, households, or institutions.

Only 12 states (25%) plan to use or are considering using preventive antiviral treatment or vaccination of close contacts of flu patients, given the high cost and limited supply of neuraminidase inhibitors and the uncertain supply and effectiveness of future vaccines.

In their conclusions, the researchers write that the state vaccination strategies are aimed more at preventing deaths than at stopping or slowing a pandemic, because for several more years there is unlikely to be enough vaccine to reduce disease transmission.

They also note that neither of the surveillance networks that most states are depending on will be likely to detect a local influenza outbreak sooner than 2 weeks into the event. At the same time, the authors say that earlier detection may not improve control or slow an outbreak.

Concerning community containment measures, the authors say the national pandemic plan sets a nonspecific precedent and that more practical nonpharmacologic containment steps, such as handwashing and avoiding mass gatherings, need to be considered for inclusion in national and state pandemic plans. "Even in this increasingly computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans," the article states.

The authors suggest that states can improve their pandemic plans by addressing these concerns in their final drafts. However, they add that to improve pandemic planning, answers to several key epidemiologic questions are needed, such as whether wearing masks and closing schools or other institutions helps stem the spread of flu.